From a correspondent

 I first became interested in the Lucy Letby (LL) case when my wife referred me to a 10 hour podcast entitled: “The Case of LL; The Facts – Crime Scene 2 Court Room”, Since, I have searched for further background to this case. Richard Gill’s website raises issues around imbalance between the prosecution and the defence, or lack of it! Also, there was toxic atmosphere at the Countess of Chester (CC) neonatal unit and LL reported problems. I worked for over 25 years anaesthetizing children down to 500g, in addition to adult anaesthesia, as well as expert witness experience. I also spent 6 months attached to a Neonatal Unit. The question of whether LL committed the alleged crimes is a difficult one to answer as (a) no one actually witnessed her doing the alleged crimes, (b) there is no obvious motive, (c) the actions would be very hard to achieve and (iv) there are other alternative explanations that were not explored by the court case, or at least the 10 hour transcript.

The Countess of Chester baby unit: The main purpose of the unit was a nursey to look after and feed babies too small and fragile to leave hospital, born at the CC. There was a small 4 bedded-neonatal unit in addition to the 4 nursery rooms. LL probably wanted to gain neonatal experience hence her involvement with the 17 cited cases.

Neonates and vulnerability: Small preterm babies easily deteriorate and die. Their organs are still developing and without the advent of neonatal units in the 1980s most would die. It is only today that a baby born prematurely before 28 to 32 weeks has a good chance of survival.

Staffing levels, staff experience and standard of care: LL was only 25 years old at the time and had only been a neonatal nurse for a few years. That is not very long and she lacked experience! She still needed further training in Liverpool to advance her career. Yet, she seemed to be one of the most senior neonatal nurses (band 5) on the unit and nowhere in the transcript do we find an older, more senior or experienced colleague other than a charge nurse who managed the duties and was not hands on. Similarly, it appears that medical cover was by paediatricians who also covered the wards and there was no doctor solely on duty for the unit. Therefore, when compared to other bigger units (i.e. Alder-Hey) the level of care was limited, so it would not be surprising if a baby deteriorates, and that happens with “prems”, outcomes are not as good. So, the evidence suggests that the CC was not up to standard, and it was an overflow unit for Alder-Hey. The CC neonatal unit has since been closed down. So were the cited incidents and deaths really due to LL or a result of a poorly supported / under-funded unit looking after sick neonates that should have been elsewhere?

The prosecution case focused on a number of methods of harming babies allegedly used by LL: (i) Distending the stomach by giving too much feed or (ii) injecting air into the stomach, (iii) injecting air into the circulation causing sudden collapse, (iv) traumatising the airway and causing bleeding, (v) dislodged tracheal and chest tubes, and (vi) adding insulin to the intravenous feed. The discussion of the pathophysiology of these mechanisms was disjointed and difficult to follow. However, the connection of LL to the sudden deteriorations and deaths in 7 seemed very compelling. However, I have to take issue with a number of the prosecution’s assertions.

(i) Over-distending the stomach with feed to an extent to cause collapse and projectile vomiting. I don’t have any experience of tube feeding prems, but projectile vomiting can be a reaction to bad / infected milk? Was LL in hurry to feed the baby? I find it hard to believe this was an attempt at murder.

(ii) Most obvious was the air in the stomach and intestines at post mortem. LL must have injected air via the gastric feeding tube, or how else did it get there? Well anyone who works in theatre or resuscitation knows during mask ventilation, which all these babies had (i.e. Neopuff), that it is very easy to blow up the stomach and intestines with air / anaesthetic gases, especially if one’s technique is not perfect. I regularly had to pass a suction catheter to empty the stomach of gas at the start of surgery to deflate the stomach and improve ventilation. I even did a study on the carbon dioxide levels that often reached the level of expired gas. However, the role of the Neopuff as a potential cause was never mentioned. So what is more likely, LL injected the air or the air got there through resuscitative efforts by stressed staff.

(iii) Some of the babies suddenly collapsed and developed a strange rash on the abdomen. Some recovered rapidly. This was said to be due to LL injecting air into the circulation. Air was found to be in the blood vessels at post mortem in some deaths. The premature baby can revert to a foetal circulation (by passing the lungs) when they become unstable and this can take time to treat (revert back). Sometimes “persistent foetal circulation” manifests itself during anaesthesia until the ductus closes fully. Point not mentioned in the case but could explain the above. Also, chest compression would cause significant sucking in of air to the heart if intravenous access lines were left open to air during the resuscitation after injecting a drug (adrenaline). LL sent a Datex about a line being left uncapped by one of the doctors. So there are other explanations and mechanisms by which air could have entered the circulation.

(iv) One of the cases had trauma to oral airway and significant blood loss, I think this was one of the twins with Haemophilia, a blood clotting disorder. LL was accused of traumatising the airway. I cannot imagine how. The likely explanation would be repeated intubation attempts, not an attempt to murder the baby by LL. I recall up to seven attempts as the neonate was difficult to intubate!

(v) LL was also accused of dislodging an endotracheal tube and a chest drain which lead to deterioration in two patients. Preterm babies are very small, endotracheal tubes can easily move and become dislodged however carefully one secures them, particularly if the neck is flexed or extended! Similarly, with chest drains, the baby had bilateral drain presumably as a result of premature lungs, and one drain became dislodged / was not working and a third drain was needed. These things happen so just because LL was present does not automatically mean it was her fault. Then there was the incident with deliberate liver injury, which equally could have occurred during chest compressions by someone else?

(vi) The addition of insulin to intravenous feeds has already been mentioned by Gill from a biochemistry and reliability of blood test perspective. I don’t fully understand this one. One baby was receiving regular intravenous nutrition made up in sealed bags from pharmacy. The baby had unexplained hypoglycaemia. For three bags it persisted and when LL was not on duty the hypoglycaemia resolved. Blood were analysed insulin and C peptide. Hypoglycaemia is common in preterm babies because their mechanisms to maintain blood glucose levels are immature (i.e. glycogen stores in the liver). The child may have had an infection as Gill says there was virus circulating. That being said it difficult to image how LL managed to injected the correct and same amount of insulin into a sealed bag on three separate occasions. There is a rigid nursing protocol involving two nurses when a new bag is put up to maintain sterility. Then there was a further insulin contaminated Dextrose infusion in a second baby. BTW, LL was not the only nurse present for both these cases.

Hence, I find it very difficult to accept the verdict that Lucy Letby was responsible for all 7 deaths and a further 6 attempts at murder. I think that her case needs to be reviewed by someone with a better understanding of neonatal medicine and how a premature baby unit is run.

Signed Lester; 20.10.2023

The Timeline of the Conspiracy

The following text is taken from Science on Trial,, I will later link to the precise location on that website, and find out if the author may be named.

After having read through multiple articles detailing the timeline of the circumstances behind of the allegations, I thought I’d provide a brief but detailed history of the sequence of events resulting in Miss Letby being arrested and charged. I’m sure many of you know this timeline already, hopefully there are more details here you will find interesting.  For those who don’t know the chronology, I hope the below is useful. That this was a fairly open conspiracy between senior consultants at the hospital, primarily Dr Stephen Brearey (he is in fact the architect) and Dr Ravi Jayaram, and later detectives at Cheshire Police assigned to the case titled ‘Operation Hummingbird’ is difficult to dispute. They’ve quite openly admitted it by clumsily showering praise on themselves following the trial in a bizarre attempt to characterise themselves as heroes. Although the record is fragmented and the sources are scattered, a reconstruction is possible nonetheless.

-On June 8 2015 Child A, a premature newborn twin, suddenly collapses on the neonatal unit. Dr Ravi Jayaram, who responds to the emergency alert, later testified that he noticed “pink patches, mainly on the torso, which seemed to appear and disappear and flit around. I had never seen anything like it before but my focus at the time was on ABC, airway, breathing, circulation.” He added: “I could not explain the sequence of events, why they had happened. I couldn’t explain why it had happened in the first place and couldn’t explain why the physiological responses to timely and appropriate interventions did not happen as they should have happened.” Dr Jayaram does not mention the skin discolouration in the clinical notes he made three hours after Child A died. He testified “I didn’t appreciate the clinical significance of this whatsoever”. When asked why he also failed to mention it to the coroner presiding over the inquest of Child A, Dr Jayaram replied: “My concluding remarks when I gave evidence is that I couldn’t explain how this had happened, It was not my job to say ‘it may have been this’ because at that time I had no evidence”.

-Around midnight on 9 June 2015, Child B’s blood/oxygen levels drop. She is blue, not breathing and limp. 

-In the early hours of 14 June 2015 Child C suddenly collapses. He is pronounced dead at 5:50am.

-On 21/22 June 2015, Child D collapses three times, the last one being fatal. Those present notice discolouration on the babie’s skin.

-Towards the end of June 2015, after Child D’s death, Dr Stephen Brearey notices that Lucy Letby is on shift for each instance of four collapses, three of them fatal, in the last two weeks. She is the only nurse present in each case. Dr Brearey shares this informal review with Dr Ravi Jayaram. He tells Dr Jayaram that nothing linked the deaths “other than one nurse”. The deaths are reported by consultants to hospital’s trust committee for serious incidents. The hospital classifies them as “medication errors” and not a “serious incident involving an unexpected death”. 

-By June 2015, Dr Brearey, Dr Jayaram and “other colleagues” all identify Miss Letby as a potential link. 

-On 29 June 2016 the entire consultant body at the hospital hold a meeting concerning the collapses. Air embolism is one of the topics discussed. That evening Dr Jayaram conducts a literature search and comes across the 1989 medical paper titled “Pulmonary Vascular Air Embolism In The Newborn”. Dr Jayaram will later testify to the court that the paper describes a series of accidental events of air embolism. The context within which the research paper studies air embolism is as an inadvertent complication of mechanical ventilation. Dr Jayaram emails links to the medical paper to colleagues the next day.

-On 2 July 2015, Dr Stephen Brearey, Eirian Powell, a nurse and ward manager responsible for the nursing staff on the neonatal unit, and Allison Kelly, director of nursing at the hospital hold a meeting. Lucy’s presence when the three deaths occurred is discussed. 

-By October 2015, seven infants have died in unusual circumstances. Dr Brearey openly suspects Miss Letby is harming children. Miss Letby will go on to be convicted for murdering five of these infants. The remaining two, despite being investigated by the police, were never bought to trial.

-On 23 October 2015 Eirian Powell emailed the findings of her own review of these collapses to Stephen Brearey. She states “I have devised a document to reflect the information clearly and it is unfortunate she [Miss Letby] is on [shift] – however each cause of death was different, some were poorly prior to their arrival on the unit and the other were ?NEC or gastric bleeding/congenital abnormalities. I have attached the document for your perusal”. 

-In February 2016 Dr Brearey orders a half-day thematic review into the deaths and collapses with the help of Consultant Neonatologist at Liverpool Women’s NHS Foundation Trust Dr Nimish Subhedar. It finds several common links in nine unusual deaths since June 2015. Four of these were never brought to trial.

-On February 15 2016, The report is sent to Ian Harvey, the hospital’s medical director and second in charge, and Allison Kelly. It includes a table of the nine deaths identified in the review, showing Miss Letby is on shift for each one. Dr Brearey requests an “urgent meeting”. Management determine Miss Letby’s presence is a coincidence. 

-On March 17 2016, Eirian Powell & Allison Kelly discuss via email how Miss Letby was a commonality in the deaths. 

-On April 7 2016, Eirian Powell moves Miss Letby to day shifts to support her wellbeing because she had been present for so many of the collapses.

-On April 9 2016, Child M suffers a dramatic drop in heart rate and breathing. This occurred during a day shift and is used to suggest that deaths and collapses “follow” Miss Letby.

-In May 2016, Dr Brearey emails Allison Kelly, flagging Miss Letby’s presence at the deaths and asking for a meeting. Allison Kelly fowards the email to Ian Harvey expressing alarm that a doctor was implicating a nurse. She tells Ian Harvey that there was no evidence but that a wider review might be needed. Allison Kelly asks senior nurse managers to examine any staffing trend linked to the deaths, adding that it was ”potentially very serious“. 

-On 11 May 2016 Dr Brearey and other doctors meet Kelly and Harvey to discuss their concerns about Miss Letby. The senior managers produce a two-page “assurance” document detailing why Miss Letby is not believed to be the cause of the unusual deaths. It suggested other NHS services may be to blame for the spike in deaths and that: “There is no evidence whatsoever against LL other than coincidence”. They agree to review all the deaths and keep Miss Letby on day shifts for three months. Dr Brearey feels his concerns have been dismissed.

-On 16 May 2016, a senior doctor tells Eirian Powell during a meeting: “You are harbouring a murderer”. 

-On 23 June 2016 newborn triplet, Child O, dies after a number of collapses. 

-On 24 June 2016 Child P, the brother of Child O, suffers an ‘acute deterioration’. He suffers a number of collapses and is finally pronounced dead at 4pm. The coroner later recorded the death as ‘prematurity’. The prosecution later claimed Miss Letby injected air into his stomach. Stephen Brearey calls hospital nursing director Karen Rees to express his concerns. He no longer wants Miss Letby working on the unit. Rees insists there is no evidence against Miss Letby and says she will take responsibility for allowing her to continue to work.

-In late June 2016 emails are exchanged between nurses, doctors and hospital executives. One of the doctors recommends calling the police. Ian Harvey replies to the chain saying concerns were being “discussed and actions taken”. 

Executive directors at the hospital meet and debate calling the police for the first time. They consider the impact of an investigation and arrest, and subsequent reputational issues and impact on the trust. They acknowledge the evidence is circumstantial and express their concerns about the unit’s leadership. They fear the doctors are carrying out a witch-hunt. The trust do not contact the police. 

The neonatal unit is downgraded to level 1 so that the sickest and most premature children are sent to neighbouring hospitals. Ian Harvey and Tony Chambers, the hospital’s chief executive, contacts the Royal College of Paediatrics and Child Health and asks them to review the neonatal unit’s service level. The hospital’s executives meet the doctors and tell them they considered contacting the police but decided to handle it in a different way. 

-By July 2016 mortality data shows there had been 14 neonatal deaths in just over a year. An internal review by the nursing director notes that higher acuity levels, higher activity and short staffing levels may have all contributed. It does not mention any concerns around any individual. Miss Letby is called to a meeting with a senior nurse and a HR Manager. She is told for the first time of her association with the infant deaths. She is visibly upset and distressed. The decision has been to place her under supervision, alongside other staff. 

-In mid-July 2016 Miss Letby is redeployed to the hospitals risk and patient safety office. Staff shortages on the neonatal unit meant supervision of her was not possible after all.

-In early September 2016, the RCPCH arrive and begin their investigation. Miss Letby is one of the first to be interviewed.

-On 7 September 2016 Miss Letby submits a formal grievance against the trust for victimisation and discrimination at being removed removed from the ward. This is after learning through her Royal College of Nursing representative of the concerns by doctors on the unit. 

–In October 2016 the RCPCH report back to Harvey and Chambers. They find that what had happened ”appears unusual and needs further inquiry to try to explain the cluster of deaths“. A draft version of the report is drawn up. It raises general concerns around short staffing and clininal practices. It notes an increased volume of cases with increased acuity levels, but states this was not significant enough to explain the high mortality rate. It also says there “no obvious factors which linked the deaths and that circumstances in the unit were not materially different from those which might be found in many other neonatal units”. However it recommends detailed case reviews are needed for each of the deaths, including examination of obstetric, pathology, nursing and post-mortem indicators. It also includes a confidential section linking the deaths with Miss Letby and the subjective concerns of Dr Stephen Brearey, the neonatal lead. This section is redacted from the version circulated to the board, the doctors and the bereaved parents.*

Ian Harvey contacts Dr Jane Hawdon, a neonatalogist, asking her to carry out a forensic review of each death. Hawdon produces a five page review but tells Harvey she did not have the time to conduct the thorough investigation the royal college had recommended. Nonetheless it cited four cases which could not be explained but would “potentially benefit from local forensic review as to circumstances, personnel etc.”

The executive managers meet again and agree that not calling the police the was the right decision as the doctors’ evidence was “unconvincing”.

-In November 2016 two and a half months have passed since Miss Letby’s grievance. During the investigation, Doctors who raised concerns about her causing harm to infants, including Brearey and Jayaram, were interviewed, with their union reps present, by an investigator. The investigation finds no evidence to justify calling in the police. Instead it finds the doctors are at fault for suspecting her of murder. ”This behaviour has resulted in you, a junior colleague and fellow professional, feeling isolated and vulnerable, putting your reputation in question,“ the grievance inquiry told Letby. ”This is unacceptable and could be viewed as victimisation“. 

-On 12 November 2016 HR prepare Miss Letby’s return to the neonatal unit.

-On 22 December 2016 Tony Chambers issues Miss Letby with a full apology on behalf of the hospital trust, and assures her family the doctors who had victimised her would be dealt with.

-In January 2017 the hospital board hold a meeting. Harvey states the RCPCH review found the incidents were down to issues of “leadership, escalation and timely intervention” and that it “does not highlight any single individual”.

In a separate meeting, Harvey and Chambers tell seven clinicians, including Brearey and Jayaram, that “things have been said and done that were below the values and standards of the trust.” Mediation between Miss Letby and both Brearey and Jayaram was demanded. They were told it would protect them from a referral to the General Medical Council (GMC), the doctors’ watchdog. The British Medical Association Rep advised them to write a letter of apology to Miss Letby. 

-In late January the doctors write to Harvey. They ask “what is the reason for the unexpected and unexplained deaths? What should we as paediatricians do now?”

-On 1 March 2017 the paediatricians write a letter of apology to Miss Letby. 

-In March 2017 the consultants seek external advice from the regional neonatal lead who agrees that several cases require further investigation. They meet again with Harvey and Chambers to ask police to investigate. At this point it was agreed. The high deaths and suspicions were raised with police through the local child death and overview panel. 

-On 27 April 2017 Detective Superintendent Paul Hughes meets Dr Brearey and Dr Jayaram at the Countess of Chester Hospital. The meeting proved decisive. Dr Jayaram said “the police, after listening to us for 10 minutes, realised this is something they had to be involved in”. Whether the name Lucy Letby was mentioned at this meeting or a little later is irrelevant. The next day Operation Hummingbird was launched, and more than a year later on 3 July 2018 Miss Letby was arrested. 

The most disturbing facts I came across while researching this piece was that two fundamentally vital pieces of  evidence cited in the trial by the prosecution, had long been prepared by the doctors before the name Dewi Evans became remotely connected.

(i) The table that showed Miss Letby on shift for all the collapses and deaths had already been built by Dr Stephen Brearey in February 2016.

(ii) The air embolus theory had already been determined as her modus operandi as early as June 2015. Dr Jayaram had been sitting on the 1989 paper since June 2015.

Furthermore whilst not discussed above, Dr Stephen Brearey just so happens to be the very doctor who finally finds the so-called ‘smoking gun’. On 13 February 2018 discovers the blood sample for Child F which apparently proves deliberate harm in the form of insulin poisoning. Incidentally, Vincent Marks is a Doctor of Medicine and Clinical Scientist who has conducted highly relevant research into the forensic aspects of hypoglycaemia. His works include: ‘Insulin Murders’, ‘Hypoglycemia: Accidents, Violence and Murder’. He claims that a fatal dose of insulin for an adult human being is around 1,000 units. Child F’s level was 4,657 units. 

*Redacted passages: “The neonatal lead [Stephen Brearey], in an effort to be thorough and explore all possibilities had identified that one nurse had been rostered on shift for all the deaths although the nurse had not always been assigned to care for that specific infant. Subsequently, the paediatric lead and all the consultant paediatricians had become convinced by the link. Although this was a subjective view with no other evidence or reports of clinical concerns about the nurse beyond this simple correlation an allegation was made to the Medical Director and Director of Nursing.

“On arriving for the visit the RCPCH Review team was told that the nurse had been moved to an alternative position around ten weeks previously without explanation nor any formal investigative process having been established. The Review team was told that the individual was an enthusiastic, capable and committed nurse who had worked on the unit for four years. She herself explained to the Review team that she was passionate about her career and keen to progress. She regularly volunteered to work extra shifts or change her shifts when asked to do so and was happy to work with her friends on the unit. The Directors understood there was nothing about her background that was suspicious; her nursing colleagues on the unit were reported to think highly of her and how she responded to emergencies and other difficult situations, especially when the transport team were involved. There were apparently no issues of competency or training, she was very professional and asked relevant questions, demonstrating an enthusiasm to lead along with a high level of professionalism.

Letter to the BMJ

Rapid response to:

John Launer: Thinking the unthinkable on Lucy Letby

BMJ 2023; 382 doi:, published 26 September 2023, cite as: BMJ 2023;382:p2197

Dear Editor

I am a coauthor of the report of the Royal Statistical Society It is deeply distressing that the police investigation into the case of Lucy Letby and the subsequent trial made all of the mistakes in our book. The jury was never told how the police investigation arrived at that list of “suspicious” events and how it was further narrowed down to the list of charges. This is a case in which a target was painted around a suspect by investigators. We call it confirmation bias, in statistics. It is also often referred to as the Texas sharpshooter paradox.

Thanks to amateurs who report their work on Twitter and YouTube, we now know how the list of charges in the Lucy Letby case evolved. It is utterly scandalous that this history was not revealed to the court. Here is the broad picture. 

Doctors reported Lucy to the police, against the wishes of the hospital board.

They told the police the exact period she had been on the ward and gave them the files on all deaths in that period and on some of the incidents: namely, exactly and only those “arrests” at which Lucy had been present.

What qualifies as an incident, what is an arrest?

There is no medical category “arrest, resuscitation” under which such events are logged in hospital administration. Probably there were about five times as many such events when Lucy was not on duty, but nobody has ever looked. There is no medical definition of such an event. No formal criteria.

“Unexpected, unexplained, sudden” are also not defined in any formal way. Nor is “stable”.

Next the absolutely unqualified, long retired, paediatrician Dewi Evans, who has a business helping out in civil child custody cases, went through those medical files looking for anomalies about which he could fantasise a murder or murder attack. His ideas that milk was injected into the stomach or air into the veins were far fetched, and later not confirmed by any other evidence. On the contrary, the actual evidence certainly contradicts the idea that Lucy Letby actually attacked any child. He never gave alternative medical explanations, as would have been the obligation of a forensic scientist. All the deaths had had a post-mortem and a coroner’s report. Every single event on the charge sheet has absolutely normal explanation. Lucy was never seen doing anything wrong.

The medical experts for the prosecution merely confirmed Evans’ diagnosis, they also did not do the job of a forensic scientist.

The defence had no experts. They had brought in one paediatrician. But at the pre-trial hearing he said he wasn’t qualified in endocrinology, toxicology, etc etc etc. 

This was Texas sharpshooter, big time. Plus utterly incompetent defence. 

Richard Gill

Member of Royal Dutch Academy of Sciences

Past president of Dutch statistical society.

Conspiracy theory, conspiracy theorists

The following text was sent to me by one of my many correspondents, wondering what to do with it, and not daring to publicise his or her ideas. I said that I could post it, so that he or she could remain anonymous. I’m not saying that the opinions here are my own opinions. One can certainly call them speculations. There is so much we don’t know, and so much that does not seem to make sense, that I think they are not idle speculations; but still, speculations they are. I will add to this post some further comments of my own, concerning the general social phenomenon that people with strange and unwelcome ideas are put away as nutty crackpots; then, if several others appear to have the same nutty crackpot idea, then they are obviously evil conspirators. The history of science is a history of crackpots: Galileo, Copernicus, Darwin, Einstein. At least, they were thought to be crackpots and they were first ignored and later fought by the establishment, the latter happening when a few people started to endorse their ideas. That’s when they became really dangerous.

From here on and till further notice, the words of my anonymous correspondent.

I’ve made several posts recently arguing that Lucy Letby didn’t get a fair trial. Some people have responded by calling me, and other with similar opinions, conspiracy theorists which led me to ask myself whether there was any conspiracy involved in the whole Lucy Letby story. What I have written here is an actual CONSPIRACY THEORY and is not based on any relevant specialist knowledge and is highly speculative so you can disregard it if you like. However, if you’re looking for a ‘possible’ explanation for the very odd police investigation, the hopelessly weak evidence used against her, the bizarre nature of the trial and the other strange observables in this case, it might be worth reading on. This is not necessarily my opinion, but my attempt to make sense of an incomprehensible conviction. It is also largely motivated by ensuring Letby is granted an appeal and a fair retrial.

If this case wasn’t political from the beginning, it certainly is now. I don’t think it was ever about justice, it was always a face-saving exercise, initiated by another failing, underfunded hospital, who knew there was doctor/consultant negligence involved in most of the unexpected deaths and events on the ward, many of which happened when Lucy wasn’t on shift. Babies dying as a result of negligence or understaffing is a bomb waiting to go off, which would have decimated the already dwindling public confidence in our NHS. That would be very damaging for the politicians who rely on public support to stay in power. Because the NHS is funded by the government and ultimately of course, the electorate.

The government, which means the electorate, fund the police too, through grants to each local force. In the last few years, the reputation of the police and public sentiment towards them has justifiably fallen dramatically and must be close to an all-time low. Is it possible that the government and senior officers were desperate to restore some faith in the police force? Cracking the ‘crime’ of the century would go down well with the public! We’ve seen how political and senior police heads roll when they screw up. This investigation was very high profile, very emotive, very long and expensive and, with their reputation in the gutter, it was important for the police to come out triumphant.

The police were called in to investigate unexplained deaths on the ward and to assess if a crime had taken place. EVERYONE who worked on that ward during that period begins the police investigation as a potential suspect. But the police began their investigation, of a potentially unfathomably serious crime scene, by strolling in and meeting with senior doctors and consultants for a briefing. They then proceeded to investigate as instructed by the doctors and consultants. Those doctors and consultants were SUSPECTS! These are the same doctors and consultants who made the accusations. Since when, in any potential murder enquiry, has the person/persons reporting the crime been discounted as a suspect before the police even reach the crime scene? Their potential negligence or the possibility that they may have been the murderer was never investigated. 

And it would look terrible for the NHS if all those doctors/consultants in just one department of just one hospital were found to be negligent by the police and their neonatal ‘expert’ (with no neonatal experience). Oh the damage that would do to the NHS, and of course the government, who pay those negligent consultants’ generous wages, but underfund the hospital so badly. It’s SO much less damaging to their reputations to pin everything on one lone murderer. It certainly takes public attention away from the failures of the more powerful parties, if the public have a single villain to target with their fury and hatred. Not to mention the money it’d probably save the NHS/government in medical negligence compensation lawsuits.

The Crown Prosecution Service (CPS) and the Criminal Justice system (CJS) are also funded by the government. Following a hugely expensive investigation by the CPS and a trial costing the electorate £Millions, can you imagine the implications for our national institutions, if she’s granted an appeal and exonerated? For starters: 1. The CJS isn’t fit for purpose. 2. The CPS isn’t fit for purpose. 3. The police force isn’t fit for purpose. 4. The NHS isn’t fit for purpose and 5. The sheepish police and CPS have to begin a new, highly expensive investigation that might lead to more highly expensive criminal proceedings against negligent doctors. Far cheaper and less damaging to leave one woman sat in a cell for the rest of her life. Plus it pleases the electorate, many of whom think she should be tortured and executed ASAP. All those votes gone if she’s even granted an appeal! Countless more millions votes gone when those services are found to have failed and she’s exonerated!

And then there’s the shame they’d all face when they have to get on their knees and give Letby a grovelling apology and pay her very substantial damages. In summary, her acquittal would be a very bad day for a lot of very powerful people and institutions. It would shatter the electability of the government who have overseen all those institutions for the last 13 years. 

A plausible alternative is that it was no one’s fault, not even the government. Perhaps just a statistical spike that anyone with a basic understanding would realise is not as unusual as it was painted by the prosecution. In fact, a leading independent statistician says a full analysis, including dozens of relevant factors (rather than just an amateur’s edit of a rota) shows that if there was a ‘murderer’ on the ward, an “unnamed nurse” and a doctor, were both more likely culprits than Letby. 

Very weirdly, Ben Myers KC, for Letby, agreed with the prosecution to exclude from the trial, statistical evidence that more or less proved her innocence, because it was confusing? It need be no more confusing than the information in this paragraph. It simply needs an independent expert to do the analysis and present the conclusions to the Jury. Why did you agree to exclude it Mr Myers? And why did you agree not to contest an absurd insulin reading, that forced Letby to say, the insulin must have been administered maliciously when there are multiple other explanations for the reading? I also understand Mr Myers had two paediatric medical experts of his own who reviewed Dr Evans’ reports and listened to his testimony. I understand they were in the courthouse waiting to testify in Lucy’s defence, waiting to challenge Dr. Evans’ testimony. Waiting and waiting in a nearby room, but never called to testify by Mr Myers. Why? And where is Mr. Myers now? There are multiple questions hanging over his defence of Letby, but he remains silent. There’s no reason for his silence…..or is there? Myers needs to explain how and WHY he failed to successfully defend her.

She was locked up for 3 years, put through a 10 month trial, found guilty and handed down the harshest sentence possible – after the Judge let jurors leave for ‘personal reasons’ and accepted majority verdicts. The CJS has a huge incentive to prevent a retrial and her possible exoneration after the way the case has been handled. 

So in summary it was in everyone’s interest that she was found guilty, except hers, and it’s in everyone’s interest that she doesn’t get an appeal, except hers.

And now it is me, Richard Gill, speaking again.

But of course, it seems to many that I also believe in idiotic conspiracy theories, and worse still, am influential enough to spread them around, like a virus. Who would believe that a British court could ever wrongly convict an innocent person! I have been labelled a crackpot and a conspirator and much worse, ending up with a recent ban on editing Wikipedia, where I had been urging editors to take account of the fact that being convicted of a crime is not synonymous with having committed a crime; and that Lucy was appealing against her conviction. Seems that Wikipedia editors in the UK do not realise that in most of the civilised world everyone has a right to an appeal, and that moreover, till the appeal is over, people are not comfortable with stating that their guilt is a fact.

Not only all that, but the Wikipedia article about myself was being vandalised by vile idiots. Fortunately some sensible people noticed this and managed on the whole to rapidly revert the vandalism. But now that I’ve been banned the Wikipedia article about me is being filled up with the most idiotic garbage.

Anyway, that’s enough for this moment, but this post will get extended soon, I am sure.

The post-it note

Is Lucy’s post-it note a confession? Whether you will see it as a confession or a cry of innocent anguish depends on whether *you* have a heart and a brain. If you read it carefully, you will see that Lucy does not say that she killed those babies. She says that *they said* she killed those babies. Yes, she does say she is evil. She thinks she is clearly a bad nurse who apparently couldn’t save those babies, despite her (possibly too energetic, and certainly not well supervised) attempts. More seriously, she had had an affair with an older married man, a doctor, who later dumped her and betrayed her. She spoke out about doctors’ mistakes and about the catastrophic hygienic circumstances in which she and her colleagues had to work. For two years, doctors had tried to have her taken off that ward, because she pissed them off. Her colleague nurses loved her for her forthrightness and lovely character. She is so sorry for the suffering she caused her parents and step-brothers. She is considering suicide. She has PTSD.

This deciphering of the note was created by , known as Mycroft on ‘X’, that is the ‘X’ formerly known as Twitter.

Contempt of court

“Contempt of court” means disrespect of a court. Now, it is certainly true that I am disrespectful of the court which convicted Lucy Letby. I think that the trial was unfair and that the judge did not understand what was going on. Nor did the jury. The jury was incomplete and the verdicts were not unanimous, yet the sentence was the heaviest possible. The defence made little attempt to defend their client and the UK tabloid newspapers had convicted Lucy long ago. On one of the days that she was arrested, the TV vans were in her street, before the police arrived to knock on her door and take her away. Six years of police investigation by a team of 60 to 70 police inspectors, including a large PR department (read: a little troll farm), did not find any conclusive proof of any wrongdoing by Lucy Letby at all. Yet already Cheshire Constabulary have signed a contract with Netflix and ITN for a documentary on their fantastic work nailing the UK’s most horrific female serial killer ever.

Now, “contempt of court” is also a very serious criminal offence in the UK, but as such, it has a very narrow definition. The definition involves the motive of the perpetrator. This is like killing someone. Killing a person might be murder. But it might be an accident. It might be caused by negligence. It is only premeditated murder if the person who killed the victim planned to do so in advance and deliberately and successfully carried out their plan. Lucy Letby is convicted of a large number of premeditated murders and murder attempts. The jury believed that she had motive and opportunity and deliberately tried in some cases numerous times to kill the same infant.

As the trial of Lucy Letby proceeded, various independent observers with a scientific background started studying the case and commenting on it on various internet sites. There was my own blog, There was Peter Elston’s “Chimpinvestor” blog, There was Scott McLachlan’s Law, Health and Technology “Substack”. There was Sarrita Adams elaborate and dedicated website, later morphed into the even more elaborate Numerous individuals of course also tweeted on the case, several FaceBook groups started up, several SubReddits were founded. Cheshire Constabulary kept a close eye on social media and dedicated websites and became more and more active in trying to suppress any support of the defence of Lucy Letby, though all those Twitter users calling for the return of hanging and for Lucy to be assassinated as soon as possible in the most horrific way, were presumably encouraged by Cheshire Constabulary.

Around May, while the trial still had a few months to run, the police apparently started to become nervous. Threatening emails were sent to myself, Peter Elston, and to Sarrita Adams, telling us that our websites must be taken down and links to those sites on social media should be removed. We know that the police also attempted to find out who was behind the Law, Health and Technology substack, but did not succeed so easily.

Of course, they found me, easily. But how did they discover the identity of the anonymous owner of, Sarrita Adams, who tried very hard indeed, for very sound personal reasons, to remain anonymous? The answer is simple: at some point Sarrita and I emailed to the court trying to alert the judge that the trial was unfair, and that important scientific evidence was hidden from the jury and the public. We did this through emails to the clerks of the court, asking them to bring our messages to the attention of the judge. However, this is not what they did. They gave the messages to police inspectors from Cheshire Constabulary, who were in court every day, hobnobbing with both the barristers, the judge, and with top NHS lawyers.

They also divulged the identity of Sarrita Adams to their internet trolls who rapidly managed to dig up a lot of dirt about Sarrita and dox her on Twitter.

The email letters which Peter, Sarrita and I were sent, are very interesting. They say that our internet activities were discovered by the police and that the police had discussed with the defence team, the defendant, and the judge, and that the judge said that what we were doing appeared to be contempt of court. We should remove our websites and remove all links to them on social media. According to the police, Sarrita and I were “associates” though we were in no way associated at all except in our common belief that the trial was unfair and the scientific evidence incorrectly interpreted. Yes, we had communicated with one another. The judge did point out that this was just his initial reaction and he couldn’t state that it was contempt of court without hearing our motivation from us. This shows again that he never received our emails to the court. Our stated motivation was to prevent a possible miscarriage of justice, not to cause a miscarriage of justice by subversion of the jury. We were attempting to contact all relevant authorities, not the jury at all. Indeed, since later the jury found Lucy guilty of the most heinous crimes, it is clear that we did not influence the jury at all.

I replied to the police by email that I would do what they asked. I did not remove my blog posts on the case but I did diligently delete links to Sarrita’s site and all tweets by myself with links to my blog or Sarrita’s website. I did not get a reply, though I asked who was emailing me and said that I wanted to talk to them, by telephone or Zoom. The letters had no phone number and no first name of whoever wrote them. I called Cheshire Constabulary by phone but they couldn’t help me because I did not know the initials or first name of whoever had emailed me.

About three weeks later, the jury was now deliberating in private. One Friday evening very late I was shocked by a knock at the door. (Actually, I had already gone to bed, but my son was visiting and woke me up. Thankfully, my wife slept through the whole thing). Local Dutch police wanted to deliver two letters to me, on paper, in person. They had been instructed to verify my identity and naturally, I did show them my Dutch passport. The letters were almost identical to the email letters which I had received earlier, and had already and immediately replied to. They did not have wet signatures, they were clearly printooouts of pdfs. Similar, but not identical to what I had already received.

So now Cheshire Constabulary had legal proof, with the help of their Dutch colleagues. that I had indeed received their letters! The letters threatened arrest next time I tried to enter the UK, and noted that contempt of court carries a two year prison sentence and a huge fine – namely, the costs of rerunning the whole trial with a fresh jury. It was pointed out that as a UK citizen I was still subject to UK law even though I lived in another country. The same thing was said to Sarrita, who lives in California, but is also a British citizen.

This was clearly intended to intimidate, and indeed it was very intimidating. I will now reproduce the original email letters and the later, paper, version. The wording is fascinating, the intention was to intimidate, but UK police cannot charge me with contempt of court without an order from a magistrate, and as Judge Goss remarked, he would need to know my actual motives before he could say that I had indeed likely committed the crime of contempt of court.

How to lie with data

This spreadsheet was shown on TV both yesterday (Friday August 18, the day of the verdicts) and at the start of the trial of Lucy Letby. Apparently, Cheshire Constabulary find this absolutely damning evidence against Lucy. And indeed, many journalists seem to agree.

The 25 events are almost all of the events at which LL was present during the periods investigated. They are suspicious because she was under suspicion when the police started their investigations. Not surprisingly, most nurses are not present at many of these events. And of course, many nurses probably work far fewer hours than LL. Many are often on administrative duties.

The doctors on the ward are of course missing. Doctors were never investigated as suspects but from the start of police investigations apparently always believed to speak gospel truth. During cross-examination, during the trial, some of them have changed various parts of their stories. Of course, unlike Lucy, they do not lie, since they could never (under oath in court, or earlier, when being interviewed as witnesses by police) be saying untruths in order to deceive.

Back to the spreadsheet. When drawing conclusions from any data it is important to know how it was gathered. It is important to know what data is missing, but would be needed draw even the most preliminary and tentative inferences.

There was an NHS investigation into the raised rates of deaths and collapses at Countess of Chester Hospital (CoCH) in summer 2015 and summer 2016. It was published in 2017 by the Royal College of Paediatrics and Child Health (RCPCH). The investigation blamed the consultants for the appalling low standard of care, and the terrible situation regarding hygiene. The RCPCH investigators actually wrote that nurse Lucy Letby could not be associated with the events, but that passage was redacted out of the published report for privacy reasons. We know that already, consultants had presented their fears to hospital management. One of them (successful TV doctor and FaceBook influencer dr Ravi Jayaram) was on TV yesterday proudly telling the world that he had been vindicated. Management was inclined not to believe them, and did not act on them, but they certainly came to the ears of the RCPCH. On publication of the report, four consultants had had enough, and went to the police with their suspicions that LL was a murderer.

Thanks to FOI requests and statistical analysis by independent scientists, we now know that the rate of events (deaths and collapses) is just as much raised when Lucy is not on the ward as it is when she is on the ward. A lot of medical information (as well as the state of the drains at CoCH) points to a seasonal virus epidemic.

The elevated rate went back to normal after the hospital was down-graded (no longer accepting high risk patients), and when the drains were rebuilt, and when the senior consultant retired, all of which happened soon after the police investigation started. Incidentally, the rate of still-births and miscarriages show exactly the same pattern.

Lucy must certainly have been a witch in order to kill babies in the womb and even when she is far from the hospital.

Those familiar with miscarriages of justice involving serial killer nurses will be familiar with this police and prosecution tactic. Is it evil or is it just stupid? (cf. Hanlon’s razor). I think it is quite simply “learnt”. Police and prosecution learn what convinces jurors over the years, and that is why the same “mistakes” are made again and again. They work!

The Lucy Letby case

Note: [20 August 2023] This post is incomplete. It needs a prequel: the history of medical investigations into two “unexplained clusters” of deaths at the neonatal ward of the Countess of Chester Hospital. It needs many sequels: statistical evidence; how the cases were selected (the Texas sharpshooter paradox) and the origin of suspicions that a particular nurse might be a serial killer; the post-it note; the alleged insulin poisonings; the trouble with sewage backflow and the evidence of the plumber; the euthanasias. For the medical material, the site to visit is the magnificent

Lucy Letby, a young nurse, has been tried at Manchester Crown Court for 7 murders and 15 murder attempts on 17 newborn children in the neonatal ward at Countess of Chester Hospital, Chester, UK, in 2015 and 2016.

She was found:– Guilty of 7 counts of murder (against 7 babies)
– Guilty of 7 counts of attempted murder (against 6 babies)
– Not guilty on 2 counts of attempted murder (against 2 of the 6 babies she *was* found guilty of attempting to murder). No decision was reached on 6 counts of attempted murder against 6 different babies. However, 2 of those 6 she was also found guilty of a different count of attempted murder. [Thanks to the commenter who corrected my numbers.]

The prosecution dropped one further murder charge just before the trial started, on the instruction of the judge. Several groups of alleged murders and murder attempts concern the same child, or twin or triplet siblings. All but one child was born pre-term. Several of them, extremely pre-term.

I’m not saying that I know that Lucy Letby is innocent. As a scientist, I am saying that this case is a major miscarriage of justice. Lucy did not have a fair trial. The similarities with the famous case of Lucia de Berk in the Netherlands are deeply disturbing.

The image below summarizes findings concerning the medical evidence. This was not my research. The graphic was given to me by a person who wishes to remain anonymous, in order to disseminate the research now fully documented on, whose author and owner wishes to remain anonymous. Note that the defence has not called any expert witnesses at all (except for one person: the plumber). Possibly, they had not enough funds for this. Crowd-sourcing might be a smart way of getting the necessary work done for free, to be used at a subsequent appeal. That’s a dangerous tactic, and it seems to me that the defence has already taken a foolish step: they admitted that two babies received unauthorised doses of insulin, and their client was obliged to believe that too.

This blog post started in May 2023 as a first attempt by myself to blog about a case which I have been following for a long time. The information I report here was uncovered by others and is discussed on various internet fora. Links and sources are given below, some lead to yet more excellent sources. Everything here was communicated to the defence, but they declined to use it in court. Maybe they felt their hands were bound by pre-trial agreement between the trial parties as to what evidence would be brought to the attention of the jury, which witnesses, etc.

An extraordinary feature of UK criminal prosecution law is that if exculpatory evidence is in the possession of the defence, but not used in court, then it should not be used at a subsequent appeal, whether by the same defence team or a new one. This might explain why the defence team would not even inform their client of their knowledge of the existence of evidence which exonerated her. Even though, it is also against the law that they did not, as far as we know, disclose evidence which they had which was in her favour. The UK law on criminal court procedure is case law. New judges can always decide to depart from past judges’ rulings.

A very important issue is that the rules of use of expert evidence is that all expert evidence must be introduced before the trial starts. It is strictly forbidden to introduce new expert evidence once the trial is underway.

UK criminal trials are tightly scripted theatre. The jury is of course incommunicado, very close to its verdict, and I do not aim to influence the jury or their verdict. I aim to stimulate discussion of the case in advance of a likely appeal against a likely guilty verdict. I wish to support that small part of the UK population who are deeply concerned that this trial is going to end in an unjustified guilty verdict. Probably it will, but that will not be the end. So much information has come out in the 9 months of the trial so far, that a serious fight on behalf of Lucy Letby is now possible. Public opinion crystallised long ago against Lucy. It can be made fluid again, and maybe it can even be reversed, and this is what must happen if she is to get a fair re-trial.

As a concerned scientist who perceives a miscarriage of justice in the making, I attempted to communicate information not only to the defence but also to the prosecution, to the judge (via the clerk of the court), and to the Director of Public Prosecutions. That was a Kafkaesque experience which I will write about on another occasion. Personally, I tend to think that Lucy is innocent. That was however not my reason for attempting to contact the authorities. As a scientist, it was manifestly clear to me that she was not getting a fair trial. Science was being abused. I tried to communicate with the appropriate authorities. I failed to get any response. Therefore I had to “go public”.

Here is a short list of key medical/scientific issues, originally copied from an early version of the incredible and amazing website, with occasional slight rephrasing and some small, hopefully correct, additions by myself. That site presents full scientific documentation and argumentation for all of the claims made there.

  1. Air embolism cannot be determined by imaging, and can only be determined soon after death, and requires the extraction of air from the circulatory system, and analysis of the composition of the air using gas chromatography.
  2. The coroner found a cause of death in 5 out of 7 of the alleged murder cases. Two of them appeared to be, in part, related to aggressive CPR, two appeared to be due to undiagnosed hypoxic-ischemic encephalopathy and myocarditis, one of the infants received no autopsy, and the other infant was determined to have died due to prematurity. It is highly unusual for the cause of death to be altered years after the fact and using methodology that is not supported by the coroner’s office.
  3. The two claims of insulin poisoning are not supported by the testing conducted, and the infants (who are still alive and well) did not have dangerously low or dangerously high blood glucose levels for any period of time. There are many physiological reasons that could explain their low blood glucose during the whole period. In one of the two cases, assumptions are being made on the basis of one test taken at a single time point, clearly inconsistent with the other medical readings, and contravening the manufacturer’s own instructions for use (see image below). The report detailing the conclusions from that single test violates the code of practice of the forensic science regulator. Moreover, it appears that some numerical error has been made in the necessary calculation, resulting in an outcome which is physiologically impossible (or the person responsible did not know about the so-called “hook effect”). The mismatch between C-peptide and insulin concentration does not prove that the excess insulin found must have been synthetic insulin. There are many other biological explanations for a mismatch. No testing was done to determine the origin of the insulin. Similarly, there are many innocent explanations for the detection of some insulin in a feeding bag.
  4. The air embolism hypothesis is confusing because it fails to explain why some children apparently perished and others did not, and it has not been supported by the minimal necessary measurements.
  5. In at least one case, Lucy is blamed with causing white matter brain injury. This claim is utterly dishonest. The infant who experienced this brain injury was born at 23 weeks gestation, and white matter brain injury is associated with such early births. Further, there is sufficient evidence that demonstrates that enterovirus and parechovirus infection has been linked to white matter brain injury in neonates, resulting in cerebral palsy.
  6. At the time of the collapses and deaths of the infants, enterovirus and parechovirus had been reported in other hospitals. There is a history of outbreaks of these viruses in neonatal wards in hospitals around the world. They especially harm preterm infants who do not yet have a functioning immune system. It is reported that many parents of the infants were concerned that their ward had a virus (as was Lucy) and that Dr Gibbs denied this was so. To date we have seen no evidence to show they did any viral testing, and if they did what the results were.

Then a fact pertaining to my own scientific competence.

Both prosecution and defence were warned long ago about the statistical issues in such cases. Both have responded that they are not going to use any statistics. They are also not using the services of any statistician. Seems the RSS report has had the opposite effect to that intended. Amusingly, the same thing happened in the case of Lucia de Berk. At the appeal the prosecution stopped using statistics. She was convicted solely on the grounds of “irrefutable medical scientific evidence”. (Here, I’m quoting from the words both spoken by the judges and written down on the first page of their > 100 page report of the reasons and reasoning which had led to their unshakable conviction that Lucia de Berk was guilty. The longest judge’s summing up in Dutch legal history). I was one of the five coauthors of the RSS report. We were a “task force”, formally commissioned by the “Statistics and the Law” section of the society. I consider it the most important scientific work of my career. It took us two years to put together. We started the work in 2020; we had seen the Lucy Letby trial on the horizon since 2017 when police investigations started and the suspect being investigated was already common knowledge.

The UK does not have anything like that because a jury of ordinary folk are the ones who (legally) determine guilt or innocence. This is a clever device which makes fighting a conviction very difficult; no one can know what arguments the jury had in their mind, no one knows what, if anything, was the key fact that convinced them of guilt. Ordinary people are convinced by what seems to be a smoking gun, they then see all the other evidence through a filter. This is called “confirmation bias”. In the Lucy Letby case, the smoking gun was probably the post-it note, and the insulin then seems to clinch the matter. The prosecution cross-examination convinces those who already believe Lucy is guilty that she moreover is constantly lying. More on all this in later posts, I hope.

Back to the insulin. Here are the instructions on the insulin testing kit used for the trial, taken from this website, the actual file is Notice the warning printed in red. Yes, it was printed in red, that was not something I changed later. (All this is not my discovery; the person who uncovered these facts wishes to remain anonymous).

The toxicological evidence used in the trial violates the code of practice of the UK’s Forensic Science Regulator (see link below). It should have been deemed inadmissible. Instead, the defence has not disputed it, and thereby obliged their own client Lucy to agree that there must have been a killer on the ward. The jury are instructed to believe that two babies were given insulin without authorization, endangering their lives. (The two babies in question are still very much alive, to this day. Probably now at primary school.)

The defence stated to me that they cannot inform Lucy of the alternative analysis of the insulin question. It appears to me that this violates their own code of practice. Do they feel bound by the weird rules of UK’s criminal prosecution practice? Their client, Lucy Letby, is herself essentially merely a piece of evidence, seized by the police from what they believe is a scene of crime. No one may tamper with it during the duration of her own trial, which is lasting 10 months! I think this constitutes an appalling violation of basic human rights. The UK laws on contempt of court are meant to guarantee a fair trial. But in the case of a 10-month trial on 22 charges of murder and attempted murder, they are guaranteeing an unfair trial.

Lucy’s solicitor refused to pass on a friendly personal letter of support to Lucy or to her parents because she had not instructed him to do so. Should one laugh or cry about that excuse? I have the impression that he is not very bright and that he may have been convinced she is guilty. If so, I hope he is changing his mind. In the UK, the solicitor does all the legwork and communication between the client and the defence team. The barrister does the cross-examinations and the court theatrics, but probably never builds up a personal relationship with his client. Lucy has been all this time prison, in pre-trial detention, far from Manchester or Hereford. This might explain the extraordinarily weak defence which has been put up so far. But it might be deliberate.

One must take into account the fact that funding for legal support is meagre. The prosecution has been working on the case for 6 or so years, with unlimited resources. The defence has had a relatively very short time, with very limited resources. Probably the solicitor and the barrister already put in many more hours than they are paid for. There are no funds for expensive scientific witnesses. It is very possible that the defence team well understands that they cannot put up a serious defence during the 9 to 10 months of the trial, but that precisely this time period, with a huge number of revelations being made outside the trial, material for a serious defence during an appeal has been “crowd-sourced”. It seems to me that this mass of high-quality independent scientific work provides plenty of grounds for an appeal, in the case that the jury hands down a guilty verdict.

Some links:

Sarrita Adams’ Science on Trial website


Scott McLachlan’s Law Health and Tech blog

LL Part 0: Scepticism in Action: Reflections on evidence presented in the Lucy Letby trial.

LL Part 1: Hospital Wastewater

LL Part 2: An ‘Association’

LL Part 3: Death already lived in the NICU Environment,

LL Part 4: Outbreak in a New NICU: Build it and the pathogens will come…

LL Part 5: The Demise of Child A

LL Part 6: The Incredible Dr Dewi Evans

LL Part 7: The Demise of Child C.

LL Part 8: The Death of Child D. Had she been left or resumed on CPAP, she might still be alive today.

Peter Elston’s “Chimpinvestor” blog

Do Statistics Prove Accused Nurse Lucy Letby Innocent? This splendid and comprehensive blog post also has a large list of links to reports and data sets. Yet more data analysis can and should be done. This site gives anyone who wants to a quick-start. And after that, two more outstanding posts…

Data obtained from FOI requests

FOI requests provided some fantastic data sets see especially×1.xlsx?cookie_passthrough=1

How forensic science should be reported in court

Forensic Science Regulator: statutory code of practice

One of numerous enterovirus and parechovirus epidemics in neonatal wards

Cluster of human parechovirus infections as the predominant cause of sepsis in neonates and infants, Leicester, United Kingdom, 8 May to 2 August 2016

Someone commissioned a pretrial statistical and risk analysis – results not used in the trial

Lucy Letby Trial, Statistical and Risk Analysis Expert Input. Who commissioned this analysis, and what did it yield? (I can give you the answer after the verdict has come out).

The RSS (statistics and law section) report – not used in the trial

Royal Statistical Society: “Healthcare serial killer or coincidence?
Statistical issues in investigation of suspected medical misconduct” by the RSS Statistics and the Law Section, September 2022

At a pre-publication meeting of stake-holders held to gain feedback on our report, a senior West Midlands police inspector told me “we are not using statistics because they only make people confused”. Lucy’s sollicitor and barrister knew well in advance of our report, were even given names of excellent UK experts whom they could consult, but did not bother to contact one of them. No statistics in our courts please, we are British! Yet the UK has the best applied statisticians and epidemiologists in the world.

Article in “Science” about my work on serial killer nurses

Unlucky Numbers: Richard Gill is fighting the shoddy statistics that put nurses in prison for serial murder. Science, Vol 379, Issue 6629, 2022.

Two subreddits on the Lucy Letby case (the Lucy Letby Science subreddit) (general)

Medical Ethics

John Gibbs, recently retired Consultant Paediatrician at the Countess of Chester
Hospital, defined Medical Ethics as “Playing God with Life and Death decisions.”
See article “Medical Ethics” on page 6 of The Messenger, Monthly Newsletter of St Michael’s, Plas Newton, Chester) – reporting on talk by Dr John Gibbs, retiring paediatrician at CoCH. Audio:

The state of forensic science in the UK “The UK’s forensic science used to be considered the gold standard, but no longer. The risk of miscarriages of justice is growing. And now a new Westminster Commission is trying to find out what went wrong. Joshua talks to its co-chair, leading forensic scientist Dr Angela Gallop CBE, and to criminal defence barrister Katy Thorne KC.”

Criminal Procedure Rules and Criminal Practice Directions

Revised rules came out earlier this year, so maybe they do not apply to a trial which started earlier. Still, they express what the Lord Chief Justice of England and Wales presently wants to promote. . See especially Section 7 of his “Criminal Practice Directions (2023)”

New expert evidence cannot be admitted once a trial is in progress

“The courts have indicated that they are prepared to refuse leave to the Defence to call expert evidence where they have failed to comply with CrimPR; for example by serving reports late in the proceedings, which raise new issues (Writtle v DPP [2009] EWHC 236). See also: R v Ensor [2010] 1 Cr. App. R.18 and Reed, Reed & Garmson[2009] EWCA Crim. 2698″. This quote comes from Note, a judge is always allowed to break with precedence. The rule is not actually a permanent rule, it is merely a description of current practice. Current practice evolves when and if a new judge sees fit to break with precedence. Obviously, he would have to come up with good legal reasons why he believes he has to do that. It’s his prerogative, his free choice. That’s the essence of case law, aka common law.

CBS Statistieken, uitkeringsaffaire, uithuisplaatsingen

Deze saga zet zich voort met een nieuwe publicatie van het CBS, Nou ja, het kwam uit anderhalf maand geleden. Ik was met andere dingen bezig …

Hierbij een eerste indruk. Er worden nu betrouwbaarheidsintervallen bepaald en men ziet meteen dat de statistische onzekerheid enorm is. Natuurlijk, worden deze berekeningen gebaseerd op statistische veronderstellingen, en die zijn altijd betwistbaar. Maar op zijn minst kunnen ze geinterpreteerd worden op een pure beschrijvend-data manier als een gevoeligheids analyse. Een brede interval laat zien dat als de data een klein beetje anders was, het antwoord totaal anders zou zijn geweest. We weten zo wie zo dat er allerlei foutbronnen zijn; we weten dat de gegevens in de data bestanden van rijksinstellingen heel ver kunnen afliggen van de ervaringen van de burgers; dat ze afhangen van allerlei definities en afspraken die hun oorsprong hebben in bureaucratische administraties.

Een belangrijke resultaat is het plaatje hieronder, waarbij statistische onzekerheidsmarges toegevoegd zijn aan een plaatje uit de eerste (en omstreden) CBS rapport. Figuur 6.1.1.

Ik heb de “kleine letters” en de “nog kleinere kleine letters” meegenomen, niet om te lezen, maar om te laten zien dat er een hele technisch verhaal bijhoort.

De eerste indruk is dat het lijntje in het midden ongeveer plat is. Dus: de nare ingreep (gedupeerd zijn) in jaar “nul” geen sterke effect heeft. Men ziet over meerdere jaren een lichte toename bij dezelfde 4000 gezinnen van maatregelen van jeugdbescherming wat, zo te zien, beste toevallig had kunnen zijn. De hypothese van “geen impact” kan niet verworpen worden op grond van deze cijfers.

Maar, dat is niet de enige mogelijke uitleg van het plaatje, en die is net zo min te verwerpen. Dat hobbeltje in de grafiek zou ook “echt” kunnen zijn, en bovendien veroorzaakt door de klap wat de belastingdienst in “jaar nul” uitdeelde. Het ziet eruit als een stijging van een half procent per jaar, over meerdere jaren. De meest aannemelijke schatting is dat 20 tot 30 (of zelfs meer) echte dubbele slachtoffers zijn; dubbele slachtoffers in de zin dat gedupeerd zijn door de uitkeringsschandaal werkelijk leidde tot een uithuisplaatsing wat anders niet zou zijn gebeurd.

Het echte effect is gedempt en uitgesmeerd door alle tekortkomingen van het onderzoek. De conclusie moet zijn: het zijn zeker tientallen en mogelijk zelfs honderd.

Overigens, zou ik graag een keer een extra cijfer willen hebben waardoor ik de statistische onzekerheid in het verschil in hoogte van deze twee waardes (blaue en groen) zou kunnen evalueren.

Er zijn ruwweg 4000 gedupeerden en die zijn gepaard één op één met vergelijkbare niet-gedupeerden. We hebben feitelijk te maken met rond de 4000 matched pairs. Het CBS weet van elk lid van elk paar of een jeugdbescherming actie plaatsvond. We hebben feitelijk 4000 waarnemingen van paren, elk waarvan een van de vier waardes kan aannemen (0, 0), (0, 1), (1, 0), (1, 1); noem deze twee gevallen (x, y). Een “1” betekent uit een huisplaatsing (of iets dergelijks), een “0” betekent geen uithuisplaatsing. We zijn geinteresseerd in de gemiddelde van de x‘en minus de gemiddelde van de y‘s. Dat is hetzelfde als de gemiddelde van alle (xy) waarden; elk ervan is gelijk aan –1, 0, of +1. Ik zou graag het 2×2 tabel willen zien van aantallen van elk van de vier mogelijke gesamenlijke uitkomsten (x, y). Ik zou de standaard afwijking willen uitrekenen van de (xy) waarden. Dit zou ons inzicht geven in de mate van success van de matching: als het goed is, zouden we een positieve correlatie zien tussen de uitkomsten van de twee groepen. Een correlatie van +1 zou impliceren dat de uitkomst volledig bepaald is door de matching variabelen, dat zou betekenen: gedupeerd zijn maakte werkelijk niks uit. Kom’ns op, CBS!

The bogeyman (Algemene Dagblad, 26 January)

date2023-01-26 09:38:02

Richard Gill. © Rob Voss

Professor Gill helped exonerate Lucia de B., and is now making mincemeat of the CBS report on benefits affair

Top statistician Richard Gill cracks down on the research conducted by Statistics Netherlands (CBS) into custodial placements of children of victims in the benefits affair. ‘CBS should never have come to the conclusion that this group of parents was not hit harder than other parents.’

Carla van der Wal 26-01-23, 06:00 Last update: 08:10

Emeritus professor Richard Gill would prefer to pick edible mushrooms in the woods and spend time with his grandchildren. Nevertheless, the top statistician in the Netherlands, who previously helped to exonerate the unjustly convicted Lucia de B, is now firmly committed to the benefits affair.

CBS should never have started the investigation into the custodial placement of children of victims in the benefits affair, says Gill. “And the conclusion that this group of parents has not been hit harder than other parents, CBS should never have drawn. It left many people thinking: only the tax authorities have failed, but fortunately there is nothing wrong with youth care. So all the fuss about ‘state kidnappings’ was unnecessary.”

After Statistics Netherlands calculated how many children of benefit parents were placed out of home (in the end it turned out to be 2090), it seemed that victims in the affair lost their children more often than similar parents who were not victims. The results were presented on November 1 last year, which Gill now denounces.

Gill is emeritus professor of mathematical statistics at Leiden University and in the past was an advisor to the methodology department of Statistics Netherlands. In the case of Lucia de B. he showed that calculations that would show that De B. had more deaths in her services were incorrect.

CBS abuses

There is a special reason that Gill is now getting stuck in the benefits affair – but more on that later. First about the CBS report. Gill states that Statistics Netherlands is not equipped for this type of research and points out that after two research methods were dropped, only one ‘not ideal, but only option’ remained. He also thinks, among other things, that the more severely affected victims in the benefits affair should be the focus of the investigation. He emphasizes that relatively mildly affected families most likely had to deal with much less drastic consequences. CBS itself also says that it likes to use information about the degree of duping, but that there was none.

CBS also acknowledges some criticisms. “CBS itself has mentioned a number of comments to the report. There seems to be a misunderstanding on one point,” said a spokesperson, who also said that CBS still fully supports the conclusions. CBS will soon be discussing the methodology used with Gill, but in any case CBS sees itself as the right party to carry out the study. “CBS has the task of providing insight into social issues with reliable statistical information and data and has the necessary expertise and techniques. In this case there was a clear social need for statistical insight.”

Gill thinks otherwise and thinks it’s important to raise this. Because he is awakened by injustice. That was also a reason to offer his help when questions arose about the conviction of Lucia de B., who can simply be called Lucia de Berk again since her acquittal. In 2003 she was sentenced to life imprisonment.

Out-of-home placement

With the acquittal in 2010, Gill became not only a top statistician, but also a beacon of hope for people who experienced injustice. And José Booij, a mother of a child placed in care, contacted him many years ago.

Somewhere in Gill’s house in Apeldoorn there is still a box with papers from José. It contains diaries, newspaper clippings and diplomas of hers. She was a little different from other people. A doctor who fell for women, fled the Randstad and settled in Drenthe. There she became pregnant and had a baby. And she had a neighbour with whom she had a disagreement. “That neighbour had made all kinds of reports about José to the local police, said that something terrible would happen to the child.” After six weeks, José’s daughter was removed from home.

State kidnapping

“What happened to José at the time, I also call that a state kidnapping, just as the custodial placements among victims of the benefits affair are now called.” The woman continued to fight to get her child back. But gradually that fight drove her insane. She lost her job, she lost her home. She fled abroad. “Despite a court ruling that the child had to be returned to José, that did not happen. José eventually derailed. I now know that she has left information with more people in the Netherlands to ensure that it is available to her daughter when she is ready. But I can’t find José anymore. I heard she was seen in the south of the Netherlands after escaping from a psychiatric clinic in England.”

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Demonstration by victims of the benefits affair. © ANP / ANP

And meanwhile he keeps that box. And Gill thinks of José, when he considers the investigation by the Central Bureau of Statistics into custodial placements of children of victims in the benefits affair. Gill makes mincemeat of it. “The only thing CBS can say is that the results suggest that the differences between the two groups that have been compared are quite small. There should be a lot more caution, and yet in the summary you see bold summaries, such as: ‘Being duped does not increase the likelihood of child protection measures’. I suspect that CBS was put under pressure to conduct this study, or wanted to justify its existence. Perhaps there is an urge to be of service.”

Time for justice

Now is the time to put that right, Gill thinks. Research needs to be done to find out what’s really going on. “I had actually hoped that younger colleagues would have stood up by now, who would take up such matters.” But as long as that doesn’t happen, he’ll do it himself. Maybe it’s in his genes. It was Gill’s mother – he was born in England – who helped crack the enigma code used by the Germans to communicate during World War II. Gill wasn’t surprised when he found out. He already suspected that his excellent mind was inherited not only from his father, but also from his mother.


Yet in the end it was his wife – the love of whom led him settle in the Netherlands – who put him on this track. She pointed Gill to Lucia de Berk’s case and encouraged him to get to work. She may have regretted that. For example, when Gill threatened to burn his Dutch passport during a broadcast of The World Keeps on Turning Round (“De wereld draait door”) if the De Berk case was not reviewed. “She said, ‘You can’t say things like that!'”

In fact, he would like to enjoy his retirement with her now – he has been out of paid work for six years now. Then he would spend his days in the woods looking for edible mushrooms. And spend a lot of time with his grandchildren. But now his calculations also help exonerate other nurses. Last year, Daniela Poggiali was released in Italy after Gill interfered with the case together with an Italian colleague. There are still things waiting for him in England.

And so the benefits affair is here in the Netherlands, which, as far as Gill is concerned, needs more in-depth, thorough research to find out exactly what caused the custodial placements. “That is why I ended up with Pieter Omtzigt and Princess Laurentien, who are also involved in the benefits affair.” Among the people who express themselves diplomatically, he wants to be the bad cop, the man who shakes things up, as he did when he threatened to set his passport on fire. But at the same time, he also hopes that a young statistician will emerge who is prepared to take over the torch.

CBS provided this site with an extensive explanation in response to Gill’s criticism. It recognizes the complexity of this type of research, but sees itself as the appropriate body to carry out that research. An appointment to speak with Gill has already been scheduled. “CBS always tries to explain as clearly and transparently as possible in its reports what has been investigated, how it was done and what the results are.”

Statistics Netherlands also points to nuances in the text of the report, for example after the sentence above a piece of text: ‘Being duped does not increase the chance of child protection measures’. “On an individual level, there may be a relationship between duping and youth protection, which is stated in several places in the report.” Even if ‘on average no evidence is found for a relationship between duping and youth protection’, as Statistics Netherlands notes.

Statistics Netherlands fully supports the research and the conclusions as stated in the report. It is pointed out, however, that there are still opportunities for follow-up research, as has also been indicated by Statistics Netherlands.